Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Cify to Provide) <br /> Please complete both side�� of the form <br /> Property Owner Section: <br /> Property Owner Name: -��`�}-�`x-`(�"^L� �� �$l/V <br /> Installation Addrr_;s: � SZ %�.I �c> � �J' U �QV 21 _ <br /> City:L I/n Y7��-- Stale: li��Zip:�� ZO� - <br /> � <br /> Mailing Address (i�dilferent): — <br /> �i�y: State: Zip: <br /> Emaii� Phone: ( ) <br /> ITolal Cost to Instaii Device(from confracfor invoice): 5�.���9_ <br /> I, the property owner, request to have the City of Eve�ett Back�vater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address.be made payable to, and <br /> senl lo,the vendor specifed on the back of this form. By requesling the rebale check be made <br /> payable to lhe vendor, I agme to the follo�ving: <br /> 7. I will not receive a rebate check directly from lhe City of Evere�t. <br /> 2 Assigning payment ot the rebale to lhe vendor does not exempt me from Backwater � <br /> Prevention Device Robale Program requiremenls. <br /> I aulhnrize the release of my rebate to the vendor lisled on the back ot this form pending <br /> approval of Ihe completed Backwater Prevention Device rebale packel by the City of Everett <br /> \ � w� 71n ht.✓' `— <br /> �n.�g'� �J <br /> Signalure of Pro�erty Owner Dale <br />